NCMHCE Practice Test 1

Presenting Problem

You are a licensed mental health counselor working in a private practice. Nadia, 36, and Graham, 38, married for 11 years, request couple counseling two months after Graham disclosed a five-month affair with a coworker. Graham says the affair ended before Nadia found messages on his laptop, which led to his disclosure. Nadia says, "I replay it all day. I check his phone every night, and I still don't believe anything he says."

Both describe arguments almost every night after their children, ages 6 and 10, are asleep. Nadia asks detailed questions about the affair and raises her voice when Graham's answers seem vague. Graham describes his response: "Whatever I say is wrong, so I go quiet." Nadia adds, "He stares at the wall, then picks up his phone, and finally he just walks out. The more he does that, the harder I push." Nadia sleeps about five hours a night, and Graham has started sleeping on the couch. Both say they want to stay married "for now." Nadia wants "to know everything that happened," while Graham says, "I want to stop living in that night and move forward."

Following your practice's standard procedure, you met with each partner individually during the intake to screen for intimate partner violence. Graham denied any physical aggression. In her individual screening, Nadia reported that three weeks ago, during an argument, Graham punched the wall beside her and stood in the bedroom doorway for several minutes so she could not leave. She said, "He's never hit me, and I'm not afraid of him. He was just desperate for me to stop yelling." She described no other incidents and asked that you not raise this in front of Graham yet. Neither partner reports suicidal or homicidal ideation, and both deny having weapons in the home.

Mental Status Exam

Both partners were appropriately dressed and well groomed and were oriented to person, place, time, and situation. Nadia described her mood as "furious and exhausted"; her affect was tearful and intense, congruent with her mood. Graham described his mood as "numb"; his affect was flat and guarded, and he looked down whenever the affair was discussed. Both had intact memory and normal motor activity and gait. Nadia kept steady eye contact with you, while Graham's eye contact was limited. Thought processes were logical and goal directed for both. Nadia's thought content centered on the affair, and Graham's on fear that the marriage will end. Neither reported perceptual disturbances, suicidal or homicidal ideation, or any history of mania or hypomania. Nadia drinks socially; Graham reports two to three beers on weekends.

Psychosocial and Family History

Nadia is a physical therapist. Graham manages a hardware store, where the coworker with whom he had the affair transferred to another location after the disclosure. Nadia grew up in a close family that attends a Maronite Catholic parish; her parents and sisters do not know about the affair. Graham's parents divorced after his father's repeated affairs when Graham was 12, and he says, "I swore I'd never be him." Finances are stable. Neither partner reported a trauma history on screening. At intake both signed your informed consent, which states that you will not keep secrets one partner shares individually if they would undermine the couple's work, with an exception for safety-related disclosures made during individual screening. During his individual meeting, Graham told you that the former coworker still texts him every few days. He says he has not replied and asks you not to mention the texts to Nadia: "It would wreck everything right when we're starting."